Neurological Disorder NCLEX | Nurselytic

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Neurological Disorder NCLEX Questions

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Question 1 of 5

The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?

Correct Answer: B

Rationale: A negative CT scan is a criterion for administering the thrombolytic therapy. Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage. History of type 1 DM is not a contraindication for thrombolytic therapy. The onset of neurological deficits within 3 hours is a criterion for administering thrombolytic therapy.

Question 2 of 5

Which instruction is most applicable after symptoms are relieved?

Correct Answer: B

Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.

Question 3 of 5

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?

Correct Answer: C

Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (
C). Assessing and relieving the trigger is the priority. Flat positioning (
A) may worsen symptoms, dimming lights (
B) is not effective, and narcotics (
D) do not address the cause.

Question 4 of 5

The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest 'Lou Gehrig’s' disease. Which is the nurse’s most appropriate response?

Correct Answer: B

Rationale: There is no information that the client is working too much. Telling the client to avoid thinking the worst belittles the client’s concern. This is the most appropriate response because it focuses on the client’s concern, encourages verbalization, and solicits more information. ALS (Lou Gehrig’s disease) is a degenerative disease that affects the motor system and does not have a dementia component; thus, a question about memory is inappropriate. This response does not take the client seriously and does not address the client’s concern.

Question 5 of 5

The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?

Correct Answer: D

Rationale: Flaccid paralysis and unresponsiveness (
D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (
A) or thrashing (
C) suggest improvement, and adduction (
B) is not a standard indicator.

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